Annexure ‘A’

भारतीय रा ीय राजमाग ूािधकरण

National Highways Authority of India
APPLICATION FOR REIMBURSEMENT OF MEDICAL EXPENSES
(HOSPITALISATION)
(To be filled by the Employees working on regular/deputation/long term contract-
two years & above)

1. Name & Designation of the Employee :

2. Date of Joining :

3. Name of the Patient and relationship :

with the Employee

4. Name of the disease of the patient :

5. Name of the approved Hospital :

6. Expenditure being claimed :

(documents to be enclosed)

(i) I certify that the statement in this application are true to the best of my
knowledge and belief and that the persons for whom medical expenses have
been incurred are wholly dependent on me.

(ii) I certify that (i) i am not a CGHS beneficiary, (ii) my husband/wife is not
availing CGHS benefit/medical benefit for himself/herself or for any dependent
member of the family, (iii) my husband/wife is/is not an employee of the
Central Govt./State Govt./Public Sector Undertaking/ Autonomous
Body/Institution etc., which are wholly/partly owned/controlled/ funded by
Central/State Governments and is/is not claiming any medical benefits under
the relevant rules applicable to them for himself/herself or any dependent
member of the family.

(iii) I Certify that my father/mother is residing & dependent on me and is not

availing CGHS benefits/Medical Benefits for himself/herself or for any member
of the family. It is also certified that my father/mother is not getting any
pension benefits.

(iv) I also certify that the claim does not include expenditure towards vitamins
(unless certified as essential by a registered medical practitioner), tonics, baby
food, milk food, beverages, spectacles, dentures, crown work, bridge work,
orthodontic work and other special dental work.

[Signature of the Employee]

Date:
 Annexure-B

Name of the Employee :

Designation :

Status :
(Regular/Deputation/Long Term Contract-Two years & above)

Sl. NO. Bill No. Date Amount (in Rs.)

Total

[Signature of the Employee]

Verified by

DDo, PIU/CMU

Project Director
 UNDERTAKING

This is to certify that the expenditure for Rs ___________ (Rs.

__________________________________ only) claimed by me for myself / my
dependent family members towards medical expenses has not/will not be claimed by
me / my family members under any Medi-Claim Policy or from any other source.

Signature :

Name :

Designation :

Date :